Academic Accommodations Application Form

Eastern New Mexico University - Roswell

Academic Accommodations Application Form

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⤶ Return to Academic Accommodations

Name

First Last

Date of Birth

Student ID Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student Email Address

What is the best way to contact you?

DISABILITY INFORMATION

Disability is defined by the ADA as “a physical or mental impairment that substantially limits one or more of the major life activities, a record of such an impairment or being regarded as having such an impairment.”

Student Status

Current ENMU-Roswell Student

Freshman

Returning Student

Transfer Student

Have you ever been diagnosed as having a disability?

Yes

No

If yes, in your own words, describe your disability below and how it has helped or hindered your academic progress:

When was the diagnosis made?

Who made the diagnosis?

ACCOMMODATIONS

What services/accommodations have you received in the past?

This application and any relevant documentation must be submitted to Disability Services Office and an intake interview completed in order to receive academic accommodations. During this meeting we will discuss services for which I am eligible. The information submitted to Disability Services Office is confidential. I know that the information submitted to Disability Services Office WILL NOT be placed in my academic records. I understand that admission to Eastern New Mexico University-Roswell is a separate process and is completed through the office of Enrollment Services

Student Signature

Date

Authorization to discuss documentation with providers In order to explore possible coverage and reasonable accommodations, it is often necessary for the director of Disability Services Office to discuss the documentation the student has submitted with providers such as licensed physicians, psychologists, or other qualified professionals. I hereby give permission for the director of Disability Services Office at Eastern New Mexico University-Roswell to exchange information regarding the documentation I have submitted with my provider(s) (physician, psychologist, or other qualified professional). I understand that my refusal to authorize consent may result in a denial of accommodations.

Student Signature

Date